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CPG # TO: OFFICE OF REVENUE AND RECOVERY <br /> ACCOUNT TRANSMITTAL Copy ACCOUNT NO. DEPT. NO. REFERRAL 026000.0 <br /> LAST - GUARANTOR - FIRST MI TITLE LAST - AKA - FIRST MI TITLE <br /> MASTER AUTO REPAIR 1 11 11 j 11 <br /> C/O NAME GUARANTOR SSN <br /> CESAR DAVILA <br /> MAILING STREET CITY ST ZIP CODE AREA PHONE NO. <br /> MASTER AUTO REPAIR 1803 SHADY FOREST WAY STOCKTON CA 95205-2588 209-464-1935 <br /> RESIDENCE STREET CITY ST ZIP CODE AREA PHONENO. <br /> 3630 GAM BEL OAK LANE STOCKTON CA 95205 209-464-1935 <br /> USER REFERENCE NO. BILL TAT CYCLE I STATUS DATE 13Md CBMd INT MONTHLY PAY AMT PYMT I HHOH <br /> 13367 HAZMAT 1.4/15/11 <br /> CHARGES <br /> LAST - RECIPIENT - FIRST MI TITLE RECIPIENT USER REFERENCE NOMARRATIVE <br /> SERVICE DATE: DATE OF <br /> START STOP MED REC NO CHARGE <br /> CHARGE DEPT. NO. DESCRIPTION AMOUNT HARGE DEPT.NO. DESCRIPTION AMOUNT <br /> 230 042000.0 2011 Hazmat Fee $115.00 380 042000.0 <br /> 230 042000.0 Haz Mat Penalty Fee $11.50 380 042000.0 <br /> 380 042000.0 Sm Hw Gen<5 Tons/yr $213.00 380 042000.0 <br /> 380 042000.0 Permit Fee Penalty $213.00 380 042000.0 <br /> 380 042000.0 State Surcharge Fee $24.00 380 042000.0 <br /> 380 042000.0 Electronic Surcharge Fee $25.00 Seo 042000.0 <br /> 380 042000.0 380 042000.0 <br /> TOTAL $601.50 <br /> GUARANTOR <br /> DOB DR LIC NO AUTO LIC NO <br /> PRIOR STREET CITY ST ZIP CODE <br /> I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MASTER AUTO REPAIR 209-464-1935 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3091 N WILSON WAY STOCKTON CA 95205 <br /> CO-OWNER <br /> AST FIRST MI TITLE SOC SEC NO. DOB DR LIC NO AUTO LIC NO <br /> I I <br /> EMPLOYER NAME EMPLOYER PHONE NO <br /> MASTER AUTO REPAIR 209-464-1935 <br /> EMPLOYER STREET CITY ST ZIP CODE <br /> 3091 N WILSON WAY STO KT CA 95205 <br /> DATE <br /> REPARED BY CHECKED BY tf 9 ' _// <br /> COL. n1 ((3M) <br />